F0584

E

Failure to Maintain Clean, Homelike Environment and Safeguard Residents’ Personal Property and Laundry

Harrisonburg, Virginia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and to protect residents’ personal property. One cognitively intact resident with multiple chronic conditions, including polyarthritis, chronic respiratory failure, diabetes, Crohn’s disease, and bipolar disorder, did not consistently receive properly sized fitted sheets for a bariatric mattress. Surveyors observed an ill‑fitting sheet that did not cover the entire mattress, and the resident reported that the correctly sized orange‑trimmed bariatric sheets were often unavailable on the unit. Staff interviews confirmed that the resident had voiced concerns about sheet availability, that the unit linen room sometimes lacked the needed sheets, and that CNAs sometimes used whatever sheet was available at shower time instead of obtaining the correct size from the laundry, despite 24‑hour access to clean linen and an adequate central inventory of the correct sheets.

Another resident with COPD, mood disorder, chronic pain syndrome, major depressive disorder, and severely impaired cognition was found in a room where housekeeping was not maintained. Over multiple days, surveyors observed scraped and damaged drywall, missing sections of wall, brown/tan drips and spatters on the wall, paper trash and candy wrappers on the floor beside and under the bed, and a dirty floor with black/gray film, drips, footprints, and black/brown specks near the toilet. A family member reported having to pick up trash from the floor and stated that housekeeping "could be better." The maintenance director was unaware of the wall damage and reported no work order had been entered, while the housekeeping supervisor and housekeeper acknowledged that rooms and bathrooms were supposed to be cleaned daily but that room changes and deep cleans sometimes prevented the housekeeper from getting to all rooms each day, resulting in some rooms only being cleaned every other day.

The facility also failed to protect residents’ personal property and to process laundry in a timely manner. One resident with moderately impaired cognition reported that pictures and other personal items were lost during room changes, particularly laminated pictures of family and pets, and that grievances had been filed without any response or apparent search for the items. Records showed two room changes and two grievances documenting missing glasses, fingernail clippers, hats, a fan, and multiple laminated pictures, with no investigation, findings, or actions recorded. Interviews with the administrator, housekeeping supervisor, social services director, and unit manager revealed that no personal belongings inventory had been completed on admission, no department had been assigned to investigate the grievances, and personal items left in a room for pest treatment were not accounted for. Another cognitively intact resident reported a shaving mirror missing for about six months; the property list did not specifically list the mirror, lacked the resident or responsible party signature, and had no dates or signatures for items added or removed, contrary to facility policy.

In addition, multiple residents reported problems with timely return of personal clothing from laundry, stating that laundry sometimes took more than two weeks to be returned, was not returned in the order sent, and that they received items that were not theirs while not receiving items sent earlier. A tour of the laundry department revealed large amounts of mixed soiled facility and resident laundry in bags at the bottom of the chute, multiple bins of soiled laundry awaiting washing, tables piled high with clean facility linen to be folded, and a long rack of clean resident clothing awaiting return to units. The EVS director acknowledged that laundry sometimes became backed up, that delays occurred, and that unlabeled items were placed in lost and found, which was only brought to units about once every two months, despite a stated goal of returning resident laundry within three days.